Predictors of critical care needs after IV thrombolysis for acute ischemic stroke.

Roland Faigle,Roland Faigle,Rafael H Llinas,Victor C Urrutia,Victor C Urrutia,Anjail Sharrief,Anjail Sharrief,Anjail Sharrief,Elisabeth B Marsh,Elisabeth B Marsh,Peter Rosenberger

doi:10.1371/journal.pone.0088652

Abstract

Background and PurposeIntravenous (IV) tissue plasminogen activator (tPA) is the only Food and Drug Administration (FDA)-approved treatment for acute ischemic stroke. Post tPA patients are typically monitored in an intensive care unit (ICU) for at least 24 hours. However, rigorous evidence to support this practice is lacking. This study evaluates factors that predict ICU needs after IV thrombolysis.MethodsA retrospective chart review was performed for 153 patients who received intravenous tPA for acute ischemic stroke. Data on stroke risk factors, physiologic parameters on presentation, and stroke severity were collected. The timing and nature of an intensive care intervention, if needed, was recorded. Using multivariable logistic regression, we determined factors associated with requiring ICU care.ResultsAfrican American race (Odds Ratio [OR] 8.05, 95% Confidence Interval [CI] 2.65–24.48), systolic blood pressure, and National Institutes of Health Stroke Scale (NIHSS) (OR 1.20 per point increase, 95% CI 1.09–1.31) were predictors of utilization of ICU resources. Patients with an NIHSS≥10 had a 7.7 times higher risk of requiring ICU resources compared to patients who presented with an NIHSS<10 (p<0.001). Most patients with ICU needs developed them prior to the end of tPA infusion (81.0%, 95% CI 68.8–93.1). Only 7% of patients without ICU needs by the end of the tPA infusion went on to require ICU care later on. These patients were more likely to have diabetes mellitus and had significantly higher NIHSS compared to patients without further ICU needs (mean NIHSS 17.3, 95% CI 11.5–22.9 vs. 9.2, 95% CI 7.7–9.6).ConclusionRace, NIHSS, and systolic blood pressure predict ICU needs following tPA for acute ischemic stroke. We propose that patients without ICU needs by the end of the tPA infusion might be safely monitored in a non-ICU setting if NIHSS at presentation is low.

Highlights

Ischemic stroke is the second leading cause of death for people older than 60 years of age, with an estimated 795,000 new strokes each year in the United States alone [1,2]
Patients with an National Institutes of Health Stroke Scale (NIHSS)$10 had a 7.7 times higher risk of requiring intensive care unit (ICU) resources compared to patients who presented with an NIHSS,10 (p,0.001)
Most patients with ICU needs developed them prior to the end of tissue plasminogen activator (tPA) infusion (81.0%, 95% CI 68.8–93.1)

Summary

Introduction

Ischemic stroke is the second leading cause of death for people older than 60 years of age, with an estimated 795,000 new strokes each year in the United States alone [1,2]. Intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (tPA) is the only Food and Drug Administration (FDA)-approved treatment for acute stroke and is currently the cornerstone of acute therapy for patients presenting within 4.5 hours of symptom onset [5]. Many patients are transferred out of the ICU after 24 hours without requiring any critical care intervention. This suggests that the unit is being used for ‘‘intensive monitoring’’ rather than ‘‘intensive care’’. Intravenous (IV) tissue plasminogen activator (tPA) is the only Food and Drug Administration (FDA)-approved treatment for acute ischemic stroke. Post tPA patients are typically monitored in an intensive care unit (ICU) for at least 24 hours. This study evaluates factors that predict ICU needs after IV thrombolysis

Objectives

Methods

Results

Conclusion